Complaint #: NJ00179638 Based on interviews, record review and review of pertinent facility documents on 11/18/2024 and 11/19/2024, it was determined that the facility failed to ensure the safety of a resident (Resident #1) when: (a) the Resident took his/her p.o. [by mouth] medication with a clear liquid which was given by Registered Nurse (RN) #1. Resident #1 drank the liquid and reported a burning sensation when swallowing and notified RN #1. It was revealed the clear liquid was a Dakin's solution [a wound cleanser solution] half-strength (Sodium Hypochlorite 0.25%); (b) RN #1 did not follow facility's proper procedure in preparing liquid solutions for wound care, and (c) RN #1 did not follow facility's procedure in accordance to professional standards of nursing practice in administration of medication in a safe and timely manner. Resident #1 did not require hospitalization after this incident. The deficient practice was evidenced by the following: According to the FRE (facility reported event), submitted to the New Jersey Department of Health (NJ DOH) on 10/29/2024 by the facility, under the Type of Incident: Other, Specify: accidental ingestion of substance and Narrative: [Name of Resident #1] .admitted on .with Dx: Aftercare following joint replacement surgery, acute and subacute endocarditis, rt [right] femur FX [fracture], ex iv [intravenous] drug use and a BIMS [Brief Interview of Mental Status] of 15. At 2:50 pm [afternoon] on 10/28/24, [initials of Resident #1] took P.O. [by mouth] medications with approximately 30-60 mls ( millimeters) of clear liquid. [Initials of Resident #1] reportedly swallowed the liquid and reported a burning sensation when swallowing. He/she notified the nurse, [ initials of RN #1] and threw the cup with the remaining liquid in the garbage. Investigation revealed the clear liquid was Dakin's solution ½ strength (Sodium Hypochlorite 0.25%). NP [nurse practitioner in house], primary care physician and poison control immediately notified . The FRE further indicated under the Narrative .3) .After a thorough investigation it has been determined the Dakins solution ½ strength (approx. 30-60 mls) was poured in the 7oz cup by [initials of RN #1 at the treatment cart. [Initials of Resident #1] interrupted the nurse and asked for the pain medication. [RN #1] carried the cup and the wound care supplies over to the medication cart to review the MAR [medication administration record] and placed the cup on top of the cart. The cup was inadvertently handed to [Resident #1] instead of water when [RN #1] administered [Resident #1]'s medication. On 11/18/2024, a review of the Resident's admission Record (AR), Resident #1 was admitted to the facility with the following diagnoses that included but not limited to: Fracture of Unspecified Part of Neck of Right Femur, Hypertensive Heart Disease without Heart Failure, Bacteremia, and Repeated Falls. A review of Resident #1's Minimum Data Set (MDS), an assessment tool that provides a comprehensive assessment of a resident's functional capabilities, dated 11/03/2024, indicated Resident #1's Cognitive Skills for Daily Decision Making was independent. The MDS further revealed in Section GG-Functional Abilities, Resident #1 required supervision or touching assistance in his/her completion of Activities of Daily Living (ADLs). A review of Resident #1's Progress Notes (PN) dated 11/03/2024 and documented electronically by Licensed Practical Nurse (LPN) #1, pt educated by primary nurse and this undersign regarding risk of going out on pass without assistance .pt agitated and requested to go AMA [against medical advice] .pt gathered belongings and took personal rolling walker outside facility .pt aware he cannot return upon AMA. On 11/18/2024, the Surveyor was notified by the Director of Nursing (DON) and License Nursing Home Administrator (LNHA) that RN #1 no longer worked in the facility and was terminated effective 11/08/2024. The DON further stated RN #1 stopped communicating with them and never answered their phone calls after the incident. On 11/18/2024, the Surveyor made call to RN#1 and call was not returned. On 11/18/2024 at 10:30 a.m. [morning], the Surveyor in the presence of RN #2 Unit Manager (UM), made a tour of nursing unit [3rd floor Sub Acute]. RN #2 UM stated there were three medications carts and one treatment cart. The Surveyor checked the treatment cart in the presence of the RN #2 UM and observed treatment and wound supplies in the cart and no residents' medications identified. The surveyor didn't observe any residents on the floor wandering near the carts. The Surveyor furthermore checked the medication carts and observed the following findings: At 10:46 a.m., [Med Cart B] - no treatment and wound supplies identified in the cart. At 10:50 a.m., [Med Cart C] - no treatment and wound supplies identified in the cart. At 10:52 a.m., [Med Cart A] - no treatment and wound supplies identified in the cart. On 11/18/2024 at 1:18 p.m. [afternoon], the Surveyor observed LPN #2, the regular nurse with medication cart [Med Cart C], performed wound care to a non-sampled resident [SR]. In an interview with the Surveyor on 11/18/2024 at 1:44 p.m. [afternoon], RN #2 Unit Manager (UM) stated medication cart is only for medications, treatment cart used for doing treatments, there should not be any treatment supplies on top of medication cart and take the treatment cart when doing the wound care. In an interview with the Surveyor on 11/18/2024 at 3:36 p.m. [afternoon], the DON in the presence of the Licensed Nursing Home Administrator (LNHA), stated, when asked regarding wound care specifically with use of liquid wound solution such as Dakin's, not normal to pour solution in drinking cup, RN did not follow proper procedure in wound care. RN made a mistake in giving the cup with Dakin's. I tried to reach out to RN to get more information after her initial statement but she never picked up or returned our calls. In an interview with the Surveyor on 11/19/2024 at 6:54 a.m., Resident #1's attending physician (AP), stated he was made aware right away of the Resident's incident and gave orders immediately. He further stated he gave orders based on the poison control recommendations and I went to see and checked [Resident's name] right away. A review of facility's policy on Wound Care, its Purpose .is to provide guidelines for the care of wounds .; under Preparation: .3. Assemble the equipment and supplies as needed . (Note: This may be performed at the treatment cart.); under Steps in the Procedure: 1. Use disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table. Place all items to be used during procedure on the clean field .8. Pour liquid solutions directly on gauze sponges on their papers; 9. Wear exam gloves for holding gauze to catch irrigation solutions that are poured directly over the wound . A review of facility's policy on Administering Medications, its Policy Statement: Medications are administered in a safe and timely manner, and as .; under Policy Interpretation and Implementation: .19. During administration of medications, the medication cart is kept closed .No medications are kept on top of the cart . N.J.A.C. 8:39-27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to prevent a fall from the bed by following the resident's plan of care during bed mobility which resulted in leg fractures and hospitalization. This deficient practice was identified for 1 of 4 residents reviewed for accidents (Resident #11). The evidence was as follows: On 7/20/22 at 12:24 PM, the surveyor observed Resident #11 sitting up in a bariatric bed (a bed designed to accommodate a higher weight capacity than standard beds) wearing a hospital gown. The resident who appeared morbidly obese stated to the surveyor that he/she had a fall in the facility a few months ago when the Certified Nursing Aide (CNA #1) attempted to change his/her incontinence brief independently. The resident stated he/she had told CNA #1 she could not do it on her own and needed another CNA to assist her, but CNA #1 continued to independently perform bed mobility anyway, and it caused him/her to fall out of the bed. The resident stated he/she spent weeks in the hospital and had injured both their right and left leg, resulting also in pain. The surveyor reviewed the medical record for Resident #11. A review of the admission Record face sheet (an admission summary) reflected the resident was re-admitted to the facility in January 2022 with diagnoses that included a history of falls, multiple sclerosis (a chronic disease where the immune system attacks nerve fibers in the brain and spinal cord causing inflammation which then alters the electrical messages to the brain), morbid obesity, unspecified fracture (break) of lower end left femur (thigh bone), and fracture of right tibial tuberosity (shin bone). A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 10/21/21 reflected that the resident had a brief interview for mental status score of 10 out of 15, which indicated that the resident had a moderately impaired cognition. It further reflected that the resident had exhibited no behaviors in the last seven days of the assessment. Section G used to assess the resident's functional status for activities of daily living (ADL), included that the resident required extensive assistance with a two-person physical assist for toileting and bed mobility (how the resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture). It further included that the resident had a functional range of motion limitation to one upper extremity and functional range of motion limitations to the bilateral lower extremities. A review of the individualized comprehensive care plan reflected a focused area that Resident #11 had a risk for falls that was initiated on 1/24/18. Interventions included to provide assistance, and to transfer as needed. The care plan was updated on 1/25/19 after a noted actual fall, and the care plan specified to include a two-person assist at all times with ADL's and bed mobility. The surveyor reviewed the progress notes for Resident #11 and identified that the resident had an actual fall from the bed on 1/14/22. A review of the Progress Notes reflected a Nurses Note dated 1/14/22 at 1:40 PM. The note indicated, Notified by staff, resident sustained fall inside bedroom. CNA was present in the room and witnessed fall. CNA states that fall occurred while she was performing a diaper change. Resident found kneeling on the floor while hanging on to the bed railing. [Resident #11] then was lowered to the ground by staff and kept comfortable. Upon assessment, resident states [he/she] was in pain but did not identify exact location of pain. Noted laceration to left lower abdomen, first aid administered. Resident has difficulty raising [his/her] lower extremities. Patient kept comfortable on the floor with pillow under [his/her] head until Emergency Medical Technician [EMT] arrived. Medical Doctor [MD] made aware, and family notified. Order received to send to emergency room [ER] for evaluation. The surveyor requested the incident/accident investigative report for Resident #11's fall that occurred on 1/14/22. A review of the Incident Report dated 1/14/22, included the CNA #1 staff statement As per CNA. While changing the resident, I turned [him/her] to [his/her] side and [his/her] legs began to slide out of bed. I eased [him/her] out of bed and went to get help. A review of the most recent annual MDS dated [DATE], reflected a brief interview for mental status (BIMS) score of 10 out of 15, which indicated a moderately impaired cognition. On 7/26/22 at 10:08 AM, the surveyor requested the corresponding hospital records for Resident #11. A review of the hospital records revealed Resident #11 was hospitalized from [DATE] until 1/28/22. The report further revealed Resident #11 was seen by the orthopedic surgeon on 1/16/22 whose impression was resident sustained .a right, non-displaced tibial plateau fracture and a left, minimally displaced distal femur fracture after a fall out of bed . On 7/26/22 at 11:11 AM, the surveyor conducted a telephone interview with the Registered Nurse/Unit Manager (RN/UM) who worked on 1/14/22. The RN/UM stated he remembered CNA #1 had called him into the room and told him Resident #11 had sustained a fall out of bed. The RN/UM stated he went into the room and assisted Resident #11 to the ground, and assessed the resident and he/she had no apparent injuries at the time except a skin tear on his/her thigh, and no sign of hip fracture or hip displacement. The RN/UM also stated Resident #11 did complain of localized pain around the skin tear but complained of generalized pain, so the resident remained on the floor until Emergency Medical Services (EMS) could transfer them to the hospital for further assessment and treatment. The RN/UM stated he believed CNA #1 was in the room alone at the time of the fall, and that CNA #1 should have called someone into the room to assist her in moving the resident during care especially with a resident that big in size. He added that you would need an extra hand to ensure the resident's safety. The RN/UM stated he did not believe the resident had a history of falls, but knew resident required a mechanical lift to get them out of bed. When the surveyor asked the RN/UM if there were any circumstances when one staff would be sufficient when a resident was assessed to require a two-person extensive assistance, and the RN/UM responded, No. He continued that staff must get someone to come help them with that resident's care. He added that in general, if they were a two-person assist, we instructed staff to get someone to ensure nothing happens to the resident or staff member such as falls or injury. The RN/UM stated prior to this incident, he had never had any concerns with CNA #1's transfers but he spoke to CNA #1 about having a second staff member when there is a two-person assistance required. On 7/26/22 at 12:13 PM, the surveyor observed Resident #11 in bed on an air mattress with their head elevated. There was lunch on the resident's bedside table. The resident informed the surveyor he/she was afraid now of another fall from the bed. The resident added that since the fall, their left leg was so sore. On 7/26/22 at 12:52 PM, the surveyor interviewed the Director of Rehabilitation Services (DRS) who stated since Resident #11 could not get out of bed or perform bed mobility (rolling side to side), the resident required an extensive, two-person physical assist. One staff member would perform the care while the other staff member maintained the resident's position, for safety. The DRS stated Resident #11 was not on therapy services before the hospitalization, but once they returned from the hospital, Resident #11 was placed on both Physical Therapy (PT) and Occupational Therapy (OT) from 1/29/22- 2/24/22. The DRS stated that per the hospital records, Resident #11 had a fall which resulted in a minimal displacement (slight shift in position) of the left distal femur (the area of the leg just above the knee joint) and a non-displaced (bone did not shift) right proximal tibia fracture (a break in the shinbone just below the knee). The RDS stated there were no circumstances when a two-person assist should be performed alone, as it could cause injury to staff as well as the resident. On 7/27/22 at 10:33 AM, the surveyor interviewed CNA #1 who was assigned to Resident #11 on 1/14/22. The CNA #1 stated she has worked at the facility for about a year and three months. She stated that she starts her shift in the morning with gathering her supplies and checking on her residents based on the assignment she was given that day. She stated that there are many ways in which she can find out what kind of care or level of assistance a resident needs, such as asking the resident directly, reviewing the [NAME] or care plan for the resident, look on the resident's chart, or ask the nurse. CNA #1 stated that she was familiar with Resident #11 and that the resident required extensive assistance because he/she had a weak right arm. The CNA #1 stated that at the time she cared for the resident, she had only been working at the facility for about six months and didn't know about a [NAME] (CNA care plan) system as she was still trying to learn things. The CNA #1 stated that she believed that the resident required one person to assist. The surveyor inquired about the fall incident that occurred on 1/14/22. The CNA #1 stated after washing the front of the resident, she needed to turn the resident to their side to perform washing to the back, so she independently pulled the sheet that was under Resident #11 and crossed their legs. CNA #1 stated she had one hand on the resident holding them and the other hand she held a washcloth, when Resident #11's left leg had begun to slip off the bed, she immediately grabbed the bed controller and lowered the bed to the floor, because she said she knew she could not independently hold the resident's weight. Once the bed was lowered, she tried to ease the resident down to the floor and onto their knees and she called out to the Housekeeper who called the RN/UM. She stated that the resident was not complaining of pain, but was more so in shock and panic from falling out of the bed and was more so scared than in pain. The CNA #1 told the surveyor that she had the resident on her assignment once more when the resident returned to the facility, and another male CNA assisted her that day. The surveyor asked CNA #1 how many residents were on her assignment that day and CNA #1 stated she believed 11 or 12, but usually it was 13 residents. CNA #1 stated she was sure there were only four CNA's that day because if there had been five CNA's, she would not have had Resident #11's room on her assignment. On 7/27/22 at 12:15 PM, the surveyor reviewed the Daily Assignment Sheet provided by the Assistant Director of Nursing (ADON) which revealed on 1/14/22 during the 7:00 AM to 3:00 PM day shift, they had four CNA's assigned to work on the third floor. At that same time, the surveyor reviewed the facility provided census for the third floor on 1/14/22 which revealed there were a total of 54 residents residing on the third floor that day, making the ratio one CNA to every 13 residents. On 7/27/22 at 12:20 PM, the surveyor interviewed the Director of Nursing (DON) in the presence of the survey team. The DON acknowledged that according to the fall investigation CNA #1 independently turned Resident #11 during care, but according to the resident's care plan and quarterly MDS dated [DATE] prior to the fall, the resident required a two-person physical assist for bed mobility and toileting. Together the surveyor and the DON reviewed the facility provided Incident Report for Resident #11's fall investigation's conclusion which revealed In conclusion resident sustained a witnessed fall when CNA #1 turned [him/her] and [he/she] was lowered to the floor. The DON acknowledged there was no mention of cause regarding the one-person assist when two-person assistance was required. The DON further acknowledged there was no documented re-education provided to CNA #1 directly after the fall incident and no competencies were immediately performed. The DON stated it was important that CNA #1 should have been re-educated regarding safe care for Resident #11 regarding bed mobility to prevent future accidents. The DON was able to provide the surveyor a copy of the CNA [NAME] at the time of the the fall that occurred on 1/14/22. The [NAME] revealed that the resident required one person for bathing. (This did not correspond with the care plan that was updated on 1/25/19 that indicated the resident required a two person assistance for ADL care and bed mobility). The DON stated that the resident was one person for bathing, but confirmed if the resident was going to be turned during the bathing process, it would require two people to turn the resident. At that time also, the surveyor and the DON reviewed the facility provided census for 1/14/22 as well as the Daily Assignment Sheet for the CNA's for 1/14/22. The DON acknowledged there were four CNA's assigned to the 7:00 AM to 3:00 PM day shift for the third floor and that the resident census for that day was 54, a ratio of one CNA to every 13 residents. The DON acknowledged that the resident had leg fractures and an unplanned hospitalization. There were no other incidents regarding the CNA #1 or Resident #11. A review of the facility's Bath, Bed policy revised 2018, included under General Guidelines 1. Review the care plan to determine any special needs of the resident .a. Instruct the resident to turn on his/her side with his/her back toward you. (Note: Be sure the side rail is up on the opposite side of the bed to prevent the resident from rolling out of bed.) b. If the resident cannot turn by himself or herself, assist as needed . A review of the facility's Identifying Neglect policy dated 2/10/22, included preventing resident neglect is a priority throughout all levels of this organization .neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical pain, mental anguish, or emotional distress; any situation in which the resident's care needs are known (or should be known) by staff (based on assessment and care planning), and those needs are not met due to other circumstances, can be defined as neglect; circumstances that lead to neglect: .lack of sufficient staffing .poor staff oversight and/or performance evaluations NJAC 8:39-27.1 (a)